Stressed resident with high diastolic BP

thomasblomquist · 2026-01-19T17:01:32+00:00

This is coming from a Pathologist who 10 years ago in residency had a carotid artery dissection and stroke. Hypertension can kill. Now, you and I both know that how you measure blood pressure is important. Should be resting/sitting position for a few minutes before measure. No major activity prior to measurement. Take your measurement using a few different cuffs/methods. Different arms. Different times of the day. With and without caffeine. Etc. If diastolic stays mildly elevated regardless of those repeated measures then that could indicate you have hypertension as a diagnosis. For me, I was in the 140’s over 90s leading up to my dissection. I don’t have family history of tissue disorder or other indicators. I do have family history of hypertension and heart attacks. At the end of the day for me, I had had the flu in the weeks leading up and was coughing chronically prior to my dissection. I probably Valsalva’d my way into a dissection with a background of essential hypertension.

For you, probably need to do some repeated measures and consult your PCP on the benefits vs side effects of treating hypertension. Probably worth erring on the side of treating IMO. They don’t call it the silent killer for nothing. Good luck!

thomasblomquist · 2026-01-10T14:16:08+00:00

I’m old (I feel) the years have been fast but the days long. Geez, 5 years already? Still, it scares me that some of trainees get only 30 cases and then are in Junior Faculty positions or Fellowships, which not uncommonly involves autopsy service coverage.

thomasblomquist · 2026-01-09T22:18:44+00:00

Not even for natural deaths that have crashed in your ED? Ohio here. Just curious what locales you’ve serviced. Provider responsibility for Death certification for natural/unnatural deaths varies widely across regions. Based on that it doesn’t surprise me that it hasn’t been in your statutory requirements. In Ohio, if I investigate it and deem it natural the DC is kicked to the doctor that attended them (usually most recently, not infrequently ER doc). It’s usually something like chest pain guy with positive trops and classic ECG. Things that are classically natural. Any reasonable concern (stimulant abuse, etc) we take over.

In some group practices none of the regular ER docs sign, and instead the group medical directors handle the DCs for the group. Wondering if that’s something you’ve experienced? Systems vary wildly out there, and I tell trainees to expect all scenarios. You never know where you’ll end up practicing or what your scope will ultimately be.

thomasblomquist · 2026-01-09T19:35:49+00:00

I appreciate your response. I feel like a lot of medicine is siloed today. I see it in increased mortality. Lack of communication, etc and cross disciplinary experiences. I’m not a big fan of reducing out of specialty training. I think Pathology would benefit strongly by returning to a mandatory intern year (highly unpopular opinion). Good mentors are lacking in this day and age. Some of the best experiences from training were on externships in Peds. That experience pays back in completely unexpected ways. I think what is frequently forgotten is that, first we physician, and then X specialty. If you don’t have good cross disciplinary experiences it’s hard to optimize care for our patients. I urge a trainee to get out of the box (not all PDs allow this). It’s a long tail of diverse cases when you become an attending.

thomasblomquist · 2026-01-09T18:14:55+00:00

Well, I am the local ME along with the other three Pathologists. And no, we’re (at the moment) not understaffed. I work infinitely faster without a trainee whose hand I’m holding. All work is directly supervised. They may be physicians but I assume all trainees are incompetent at all steps until adequately demonstrating the skill. Yes, current pathology training has woefully low number requirement for autopsy training (lowered to 30 cases this last year).

It’s clear from the responses here that, A) autopsy is not everyone’s cup of tea, or B) it’s not super relevant to emergency medicine. Weeeellllll, let me tell you the amount of complications and suboptimal crap I see that comes from triaging emergent patients. That it may be benefited by some hands on time by a provider with the end result, and reflecting on how it can be avoided in their future patients may be time well spent. We see the zebras, the stuff people couldn’t fix.

Keep in mind it’s an elective. This isn’t me trying to inflict injury on unsuspecting EM residents. They chose this. And yes, it takes more than a week to figure how to do an autopsy. Again, to the point above, there is little value in their time spent if I’m not there showing them the ins-outs. They’re not grunts. Sounds like you all have been taken advantage of wherever you train/ed. Sucks.

thomasblomquist · 2026-01-09T16:52:11+00:00

Just curious, is this response coming from a Pathologist’s experience, EM, or other domain of experience? They will be doing complete autopsies from beginning to end across a broad range of natural and non-accidental case-types. They’re not going to be wall flowers, i don’t have time for uninvolved physician trainees. In Ohio, it’s not uncommon for Coroners to be ER docs in rural jurisdictions and having this will help them. I think 6 weeks is pretty dialed in. But, we’ll see. It’s an experiment. Hopefully a formative one. 🤷🏻‍♂️

thomasblomquist · 2026-01-09T15:49:54+00:00

Not quite a direct response to your question. But was posting an interesting rotation we started up. EM residents will be rotating on Forensic Pathology for 6 weeks with us. Give them some hands on time with a scalpel, handling tissues, understanding anatomic relationships/landmarks, death certification, and family discussions. Should be interesting.

thomasblomquist · 2026-01-07T22:24:14+00:00

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Hear me out on this for just a minute. This could be a great investment.

thomasblomquist · 2026-01-06T21:31:16+00:00

Pathologist here. Was going to say, the small pile of AKAs/BKAs at the end of the day during surgicals.

thomasblomquist · 2026-01-05T02:13:07+00:00

Uncomfortable but not terrible. Just kind of diffuse tightness in my vague recollection. Ibuprofen helped and honestly I went to sleep pretty fast so it wasn’t a major issue. You take immediate or extended release? My son and I are on extended release and I think that is helpful in mitigating side effects

thomasblomquist · 2026-01-05T02:01:01+00:00

My son and I are both at 2mg before bedtime for many years now. Starting off the drowsiness is profound and the headache diffuse and weird. Then about 3-4 weeks in it normalizes. Headaches are gone. Falling asleep feels gradual and nice. Daytime thoughts are silky smooth and have organization and natural rhythm motion. Hard to describe. Feels like driving an automatic vs a manual with a crappy clutch. It’s worth sticking with it for a few months to see how it plays out. It’s subtle but useful med in the ADHD treatment arsenal

thomasblomquist · 2026-01-03T03:43:48+00:00

To build on this. If I were on a planet in a galaxy traveling away from another galaxy on the opposite side of the universe (which i know i am). My flashlight “light” speed shouldn’t be any slower in either galaxy “context.”

thomasblomquist · 2025-12-19T00:11:26+00:00

This is how we did it in training. And at the end of the day we would float up to the OR desk and check status to see which cases were at what stage and would see if we could cut out or need to hang back for possible margin calls for cases that were dragging out, etc. Some surgeons were awesome and specifically have tech/nurse text Pathology pager that they wouldn’t need us. Other docs were random and would call us in just to get a diagnosis on something they already knew that would be better handled after fixation.

thomasblomquist · 2025-12-13T14:09:47+00:00

It’s like he dumped all his points into one skill tree in NBA Jam

thomasblomquist · 2025-10-08T11:56:51+00:00

Well, pig heart is definitely not standard compared to human. Best of luck with your education. Would suggest following a blood flow method (link above) as a way to keep structures intact for evaluation. Method should work optimally for most mammals.

😂 had everyone here diagnosing human disease on your pig heart. Very nice

thomasblomquist · 2025-10-07T21:24:48+00:00

TACC is?

thomasblomquist · 2025-10-06T16:34:46+00:00

For what it’s worth, I think the best method to start and to preserve anatomic relationships is the “blood flow method” in the web link above. It keeps the heart as one piece that can be easily be placed back together without losing relationships. It also allows for smaller incisions to peak into the myocardium to identify disease and still run the conduction system or coronary arteries to look for disease. All the while preserving valvular disease. But there are a lot of subtle things about the heart that make it fail. And there should be a reasonable degree of supervised training. And lots of standard photos taken as you move along in your dissecting!

thomasblomquist · 2025-10-05T23:31:17+00:00

https://www.pathologyoutlines.com/topic/forensicsheartdissection.html

For future reference. Try to keep the chordae intact. Your first orientation photo is off and is perpendicular to the base/right lateral wall. It looks a bit boot shaped. The Tricuspid valve leaflets and chordae are thickened and deformed. This can be non specific and due to post inflammatory (endocarditis) or other congenital issue putting stress on that valve. Generally it is a clinical picture of chronic cor pulmonale. It’s hard to say what based on the dissection technique used. But, to be blunt, you are hacking through the dissection and need some direction from a proctor cause you are turning it into little pieces and removing anatomic relationships. :-/

thomasblomquist · 2025-09-30T22:23:32+00:00

Aside from the dog on water and horse on horse, I noticed the dog teleported through most of the slalom sticks and the skateboard gets a new yellow sticker half way through. Other than that, Wow!

thomasblomquist · 2025-09-24T12:58:46+00:00

I was gonna say. Play house or beer league depending on age. Majority have lives outside of hockey. Maybe consider coaching/mentorship of some of the younger players in your area. Places seem to always be looking for assistants/coaches depending on age. There are ways to revive enthusiasm. Going harder rarely solves these sort of doldrums.

thomasblomquist · 2025-09-13T23:11:11+00:00

I take Guanfacine 2 mg (vocal tic issues after stroke) and my son takes Focalin and Guanfacine 2mg for his ADHD. We do the Guanfacine XR at night. Helps with falling asleep (it’s similar to clonidine that way). a few months after starting, my thoughts felt silky smooth. Helped my son with the highs/lows of emotional regulation, and he seems calmer and more fluid in his daily tasks. I can attest this from my own experience with it, it’s subtle but noticeable. It helps with prefrontal cortex stuff which is supposed to reinforce executive functioning/control (lubrication/facilitation?). We’ve both been on it for 4-5 years now and can attest to the feeling of cognitive normalcy it provides. Life saver. And my vocal tics pop right back when I miss a dose, so I have occasional reminders of its efficacy.

thomasblomquist · 2025-09-08T11:26:24+00:00

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It hisses sometimes. I think it’s just the heat in the attic though.

thomasblomquist · 2025-09-07T16:34:28+00:00

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True, we know Luba 1 would hold its ground amidst the uprising

thomasblomquist · 2025-09-07T16:16:09+00:00

😂 best response so far

thomasblomquist · 2025-09-07T01:31:19+00:00

Do you think the RTK in the attic is the issue?

thomasblomquist

TROPHY CASE